Provider Demographics
NPI:1134695091
Name:DILLER, AUTUMN MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:DILLER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 880
Mailing Address - Street 2:
Mailing Address - City:ST. IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:406-745-3529
Practice Address - Street 1:1 WOODCOCKS WAY
Practice Address - Street 2:
Practice Address - City:ST. IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-32707101YA0400X
MT32707101YA0400X
IDLCSW-419961041C0700X
IDLSW41996104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical